Long-Term Care

Long Term Care Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

* Email Address

Street Address

City

State

Zip Code

Phone Number

Alternate Telephone

Fax Number

Birth Date

Gender

Male

Female

Height (example 5'8")

Weight (lbs.)

Are you married?

Yes

No

If so, Spouse's Birth Date

Height (spouse)

Weight (spouse)

Fill in spouse if spouse is also applying

Do you smoke?

Yes

No

Spouse smoke?

Yes

No

Are you diabetic?

Yes

No

Spouse diabetic?

Yes

No

Are you insulin dependent?

Yes

No

Spouse insulin dependent?

Yes

No

Do you use a cane?

Yes

No

Spouse use a cane?

Yes

No

Do you use a walker?

Yes

No

Spouse use a walker?

Yes

No

Do you use a wheelchair?

Yes

No

Spouse use a wheelchair?

Yes

No

Do you use any other equipment?

Yes

No

Spouse use any other equipment?

Yes

No

Please explain if you have required assistance with everyday activities in the past 2 years:

Please explain if your spouse has required assistance with everyday activities in the past 2 years:

In the past 5 years have you: (check all that apply)

been confined to a hospital?

nursing home?

had home care?

had long-term care?

received rehabilitation?

Please describe your particular health problems:

In the past 5 years has your spouse: (check all that apply)

been confined to a hospital?

nursing home?

had home care?

had long-term care?

received rehabilitation?

Please describe your spouse's particular health problems:

Prescribed Medications:

Spouse's Prescribed Medications:

Do you currently own a long-term care policy?

Yes

No

Does your spouse currently own a long-term care policy?

Yes

No

Best Time To Contact You

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

Or Specify Other:

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